No abstract

The first section of this paper reviews the literature on the incidence, clinical findings, and outcome of anorexia nervosa. Methodological problems with outcome statistics and data on the family background of anorexic patients are discussed. The remainder of this paper evaluates the etiological and therapeutic approaches of psychodynamic, family interactional, behavioral, and medical models. The problems inherent in viewing anorexia nervosa as either a physiological or psychological disorder are considered. The importance of continuing research into all facets of anorexia nervosa is emphasized.

A study was undertaken to determine whether it is possible to identify distinct and theoretically meaningful differences between two forms of therapy used in the treatment of depression: cognitive-behavioral therapy (C/B) and interpersonal therapy (IPT). Six videotapes of actual therapy sessions in each of the treatment modes were presented to 12 naive raters. Each rater listened to and/or viewed four tapes, two from each of the therapeutic schools. For each tape, raters completed a 48-item Likert-type rating scale designed for use in this study. In addition, experts in both of the therapeutic modes were asked to indicate the characteristics of a "good^typical" C/B or IPT therapy session using the same scale. Analysis of the data obtained from naive raters indicated that 38 of the items discriminated between the types of therapy at p < .05 or greater. The direction of the differences observed was generally consistent with the experts' predictions. Factor analysis of the data yielded four principal factors, two related to modality-specific techniques and two related to nonspecific factors. No consistent bias attributable to observational medium (audio vs. audiovisual) was obtained. It appears from this study that relatively naive raters working from taped samples of actual clinical practice can detect clear procedural differences between two types of therapy and that these detected differences are related to the differences expected by experts associated with each approach.

Operant conditioning appears to be an effective short-term method of weight restoration in anorexia nervosa, although it may offer only modest advantages over alternative methods of inducing weight gain. Programs differ widely in the selection of treatment setting, target behaviors, positive and negative reinforcers, reinforcement schedules, facilitating conditions, and supplementary modalities employed, and it remains unclear how each of these variables may contribute to treatment outcome. The scarcity of long-term follow-up data after 20 years of investigation is puzzling; by default, the calculation of risk/benefit ratios has depended on the theoretical biases of the observer. The accumulation of clinical experience does appear to have had some moderating effect on the polarized positions initially assumed by the advocates and opponents of operant conditioning. The approach has gained acceptance as a useful but circumscribed component of multimodal treatment programs, and in recent years is often supplemented with a variety of behavioral and cognitive-behavioral strategies designed to deal with a broader range of anorexic symptomatology.

One of the most controversial dimensions along which developing therapeutic approaches for bulimia can be differentiated is their allegiance to an “abstinence” or “nonabstinence” model. Through analogy to traditional treatment programs for chemical dependency, many self‐help and professional programs for bulimia hold that the complete elimination of binge‐vomiting behavior is a prerequisite for therapeutic work, and require abstinence from the inception of treatment. In contrast, the nonabstinence model suggests that a more gradual reduction in the frequency of episodes may be preferable in that it provides more opportunities for relapse prevention training and avoids reinforcing dichotomous thinking styles. The present paper reviews the theoretical and clinical arguments that have been advanced by each side, including the case for classifying bulimia as a substance abuse disorder. A strategy for investigating the relative efficacy of the two approaches is proposed. It is suggested that particular attention be paid to such variables as differential attrition, the effect of each modality on the accuracy of self‐report, the need for continuing or supplementary therapy, the occurrence of treatment “casualties,” interactions between client characteristics and mode of therapy, and long‐term results. In the interim before such data are available, a reasonable clinical recommendation may be the implementation of a “compromise” approach designed to maximize the advantages claimed by each model while minimizing possible risks.